Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the "Punjab model")Debasish Basu, Ajit AvasthiJanuary-March 2015, 57(1):9-20DOI:10.4103/0019-5545.148509 PMID:25657452

Background: Substance use disorders are believed to have become rampant in the State of Punjab, causing substantive loss to the person, the family, the society, and the state. The situation is likely to worsen further if a structured, government-level, state-wide de-addiction service is not put into place.
Aims: The aim was to describe a comprehensive structural model of de-addiction service in the State of Punjab (the "Pyramid model" or "Punjab model"), which is primarily concerned with demand reduction, particularly that part which is concerned with identification, treatment, and aftercare of substance users.
Materials and Methods: At the behest of the Punjab Government, this model was developed by the authors after a detailed study of the current scenario, critical and exhaustive look at the existing guidelines, policies, books, web resources, government documents, and the like in this area, a check of the ground reality in terms of existing infrastructural and manpower resources, and keeping pragmatism and practicability in mind. Several rounds of meetings with the government officials and other important stakeholders helped to refine the model further.
Results: Our model envisages structural innovation and renovations within the existing state healthcare infrastructure. We formulated a "Pyramid model," later renamed as "Punjab model," where there is a broad community base for early identification and outpatient level treatment at the primary care level, both outpatient and inpatient care at the secondary care level, and comprehensive management for more difficult cases at the tertiary care level. A separate de-addiction system for the prisons was also developed. Each of these structural elements was described and refined in details, with the aim of uniform, standardized, and easily accessible care across the state.
Conclusions: If the "Punjab model" succeeds, it can provide useful models for other states or even at the national level.

Introduction: Sexual dysfunction can occur due to biological problems, relationship problems, lack of proper sexual knowledge or a combination of these. India is often known as the land of Kamasutra. But as far as sexuality research is concerned, there is a paucity of relevant data from India. In view of this, we conducted a study to assess the psychosocial profile of males presenting with sexual dysfunction to psychiatry out-patient department of a tertiary medical hospital.
Materials and Methods: Hundred consecutive male patients presenting with sexual dysfunction were screened using Arizona Sexual Experiences Scale for clinical sexual dysfunction and after obtaining their informed consent were included in this study. They were assessed using a semi-structured proforma, Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision criteria, Mini-International Neuropsychiatric Interview, and Dyadic Adjustment Scale.
Results: Majority of our respondents were in the 18-30 years age group and were married. The main source of sex knowledge for 69% of them was peer group. Age of onset of masturbation was 11-13 years for 43% of them. Premature ejaculation was the most common sexual dysfunction seen in the respondents. Marital discord was seen in significantly lesser number of respondents (32.35%) as also major depressive disorder that was seen in only 16%.
Discussion: Premature ejaculation was the most common sexual dysfunction in our sample. Despite the sexual dysfunction, marital discord and depression were seen less commonly in our respondents.

Background: Of various spiritual care methods, mindfulness meditation has found consistent application in clinical intervention and research. "Listening presence," a chaplain's model of mindfulness and its trans-personal application in spiritual care is least understood and studied.
Aim: The aim was to develop a conceptualized understanding of chaplain's spiritual care process based on neuro-physiological principles of mindfulness and interpersonal empathy.
Materials and Methods: Current understandings on neuro-physiological mechanisms of mindfulness-based interventions (MBI) and interpersonal empathy such as theory of mind and mirror neuron system are used to build a theoretical framework for chaplain's spiritual care process. Practical application of this theoretical model is illustrated using a carefully recorded clinical interaction, in verbatim, between chaplain and his patient. Qualitative findings from this verbatim are systematically analyzed using neuro-physiological principles.
Results and Discussion: Chaplain's deep listening skills to experience patient's pain and suffering, awareness of his emotions/memories triggered by patient's story and ability to set aside personal emotions, and judgmental thoughts formed intra-personal mindfulness. Chaplain's insights on and ability to remain mindfully aware of possible emotions/thoughts in the patient, and facilitating patient to return and re-return to become aware of internal emotions/thoughts helps the patient develop own intra-personal mindfulness leading to self-healing. This form of care involving chaplain's mindfulness of emotions/thoughts of another individual, that is, patient, may be conceptualized as trans-personal model of MBI.
Conclusion: Chaplain's approach may be a legitimate form of psychological therapy that includes inter and intra-personal mindfulness. Neuro-physiological mechanisms of empathy that underlie Chaplain's spiritual care process may establish it as an evidence-based clinical method of care.

Emperor Ashoka is widely regarded as one of the greatest rulers of India. This paper mainly deals with his medical condition as recorded in the Buddhist texts of Sri Lanka as well as in the Buddhist texts of North India and Nepal. These sources mention his skin disorder which is described as very rough and unpleasant to touch. He is also known to have episodes of loss of consciousness at various times in his life. One of the earliest representations of Ashoka, about 100 years after his death at one of the gates of Sanchi Stupa, shows Ashoka fainting when visiting the Bodhi tree and being held by his queens. In this sculpture, Emperor Ashoka is shown as a man of short height, large head and a paunchy abdomen. In this paper, it is speculated that Emperor Ashoka was probably suffering from von Recklinghausen disease (Neurofibromatosis Type 1), which could explain his skin condition, episodes of loss of consciousness (probably epilepsy) and other bodily deformities.

Background: Eating disorders (EDs) are an emerging concern in India. There are few studies comparing clinical samples in western and nonwestern settings.
Aim: The aim was to compare females aged 16-26 years being treated for an ED in India (outpatients n = 30) and Australia (outpatients n = 30, inpatients n = 30).
Materials and Methods: Samples were matched by age and body mass index, and had similar diagnostic profiles. Demographic information and history of eating and exercise problems were assessed. All patients completed the quality-of-life for EDs (QOL EDs) questionnaire.
Results: Indians felt they overate and binge ate more often than Australians; frequencies of food restriction, vomiting, and laxative use were similar. Indians were less aware of ED feelings, such as, "fear of losing control over food or eating" and "being preoccupied with food, eating or their body." Indians felt eating and exercise had less impact on their relationships and social life but more impact on their medical health. No differences were found in the global quality-of-life, body weight, eating behaviors, psychological feelings, and exercise subscores for the three groups.
Conclusion: Indian and Australian patients are similar but may differ in preoccupation and control of their ED-related feelings.

Ms. V, a 10-year-old girl was referred to Child Psychiatry Department with complaints of bleeding from eyes for last 3 months. Bleeding was spontaneous, recurrent, painless, and self-limited. History revealed significant Psychological stressors, Temperamental Difficulties and Conflicts with Mother. Mental status examination revealed Depression in Ms. V. During hospital stay, Ms. V developed repeated bleeding episodes. The presence of hemoglobin is confirmed in the bleeding sample. Hematologic investigations and computed tomography brain were normal. Ms. V was started on Sertraline, Propranolol, and Clonazepam. Both Ms. V and her Mother were psycho-educated about the nature of the illness. Ms. V was discharged and under follow-up. This case is reported for the rarity of presentation (bleeding from Eyes) of a childhood Depression.

Aim: To assess the health-care needs of the patients with severe mental disorders.
Materials and Methods: Patients with the diagnosis of a severe mental disorder (schizophrenia and related psychotic disorders, bipolar disorder, recurrent depressive disorder, major depressive disorder and obsessive compulsive disorder) were assessed using Camberwell Assessment of Need-Research version (CAN-R) Scale and indigenously designed Supplementary Needs Assessment Scale (SNAS).
Results: The study included 1494 patients recruited from 15 centers. The most common diagnostic group was that of affective disorders (55.3%), followed by psychotic disorders (37.6%). The mean number of total needs as perceived by the patients was 7.6 on the CAN-R. About two-third of the needs as assessed on CAN-R were met, and one-third were unmet. On CAN-R, main domains of needs as reported by patients were those of money, welfare benefits, transport, information about the illness and treatment, relief of psychological distress, company, household skills and intimate relationships. On SNAS, the mean number of total needs as perceived by the patients was 7.6 of which 4.1 were met needs. The most common domains of needs as assessed on SNAS were those of financial help, medical reimbursement, psychoeducation, free treatment, certification of mental illness, flexible work/job timings, addressing the caregiver stress and legal aid.
Conclusion: About two-third of the needs, of the patients with severe mental disorders are met as assessed using CAN-R. However, higher percentages of unmet needs are identified on SNAS. In view of the commonly reported needs, a change in the orientation of services offered to people with mental disorders is very much called for. At the government level, desired policies must be formulated to support the patients with mental disorders.

Finger patterns and age of onset for the determination of the parent-of-origin in the transmission of schizophreniaR Ponnudurai, J JayakarJanuary-March 2015, 57(1):30-36DOI:10.4103/0019-5545.148513 PMID:25657454

Summary: Dermatoglyphic traits which are reported to be largely determined by genes could be considered as phenotypic characterestics and if the same are expressed through generations in schizophrenic families it can be speculated to serve as genetic markers for schizophrenia. Another factor that might be influenced by genes is the age of onset of the illness in the offspring and the parent of origin.
Objective: This study was aimed to elucidate the occurrence of identical finger patterns in the schizophrenic patients and their affected parents. The other objective was to assess the age of onset of the illness in them.
Methods: Forty six schizophrenic patients in whom one of the parents was also affected with schizophrenia or related disorders were recruited. Of these pairs 29 were taken up for finger patterns analysis, with an equal number of control group pairs. 35 proband and parent pairs were investigated for the age of onset of the illness.
Results: The frequency of occurrence of identical patterns in the right thumbs of proband and their affected mother pairs was significantly more than between the proband and their affected father pairs. Additionally, the number of identical patterns was also more in the right thumbs of proband and their affected mother pairs compared with the control group. The difference between the mean age of onset of the illness in the probands and their affected fathers was more than between the probands and their affected mothers.
Conclusion: The genetic association of schizophrenic patients with the affected maternal side appear to be more stronger than with the paternal side.

Context: Development of the cultural formulation interview (CFI) in DSM-5 required validation for cross-cultural and global use.
Aims: To assess the overall value (OV) of CFI in the domains of feasibility, acceptability, and utility from the vantage points of clinician-interviewers, patients and accompanying relatives.
Settings and Design: We conducted cross-sectional semi-structured debriefing interviews in a psychiatric outpatient clinic of a general hospital.
Materials and Methods: We debriefed 36 patients, 12 relatives and eight interviewing clinicians following the audio-recorded CFI. We transformed their Likert scale responses into ordinal values - positive for agreement and negative for disagreement (range +2 to −2).
Statistical Analysis: We compared mean ratings of patients, relatives and clinician-interviewers using nonparametric tests. Clinician-wise grouping of patients enabled assessment of clinician effects, inasmuch as patients were randomly interviewed by eight clinicians. We assessed the influence of the presence of relatives, clinical diagnosis and interview characteristics by comparing means. Patient and clinician background characteristics were also compared.
Results: Patients, relatives and clinicians rated the CFI positively with few differences among them. Patients with serious mental disorders gave lower ratings. Rating of OV was lower for patients and clinicians when relatives were present. Clinician effects were minimal. Clinicians experienced with culturally diverse patients rated the CFI more positively. Narratives clarified the rationale for ratings.
Conclusions: Though developed for the American DSM-5, the CFI was valued by clinicians, patients and relatives in out-patient psychiatric assessment in urban Pune, India. Though relatives may add information and other value, their presence in the interview may impose additional demands on clinicians. Our findings contribute to cross-cultural evaluation of the CFI.

Context: Recent studies have demonstrated that a high proportion of irritable bowel syndrome (IBS) patients shows an association with psychological factors. A few studies were conducted on the investigation of psychological features of IBS patients in Iran.
Aims: We aimed to evaluate the relationship of psychological distress with IBS in outpatient subjects.
SettingsandDesign: A total of 153 consecutive outpatients met Rome III criteria, and 163 controls were interred to study and invited to complete the Symptom Checklist-90-Revised (SCL-90-R) instrument in order to assessment of psychological distress.
StatisticalAnalysis: Univariate (t-test and Chi-square) and multivariate (logistic regression) methods were used for data analysis.
Results: A significant association of IBS with all nine subscale and three global indices including global severity index (GSI), positive symptom distress index (PSDI), and positive symptom total (PST) of the SCL-90-R were detected. Patients with IBS reported significantly higher levels of poor appetite, trouble falling asleep, thoughts of death or dying, early morning awakening, disturbed sleep, and feelings of guilt compared to the controls. Multivariate analysis indicated that interpersonal sensitivity, somatization, paranoid ideation, depression and phobic anxiety subscales, and PST, PSDI, and GSI global indices were significantly associated with IBS (age, gender, educational level, marital status, employment status, smoking, alcohol use, and body mass index).
Conclusions: Psychological features are strongly associated with IBS; notably, interpersonal sensitivity, somatization, paranoid ideation, depression, phobic anxiety, and all global indices including PST, PSDI, and GSI is significantly associated with. Hence, the appropriate psychological assessment in these patients is critically important.

The frontal lobes of the brain are notoriously "silent": Benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large. We present two cases with symptoms suggestive of depressive episodes, which on further investigations showed space occupying lesions suggestive of frontal meningiomas.

Objective: The aim was to study the effect of short-term Yoga therapy program on quality of life in patients suffering from psychosomatic ailments.
Methods: Sample size and Study period: All the subjects coming to SVYASA AROGYADHAMA in month of July 2011 for Yoga therapy for various psychosomatic ailments and were free of any primary psychiatric illness and volunteering to participate were enrolled in the study after taking informed consent. Their physical condition was healthy enough to practice Yoga as judged clinically. All subjects (n = 94) who were enrolled in the study underwent Integrated Approach to Yoga Therapy, which included Asanas, Pranayamas, meditation, Kriyas and lectures on practice of Yoga and derived special techniques in their respective sections. The quality of life was assessed by SF-12 questionnaire and thereby calculating Physical and Mental Composite Scores (PCS and MCS) before and after 1 week of Yoga therapy. Data thus obtained was analyzed using paired t-test.
Results: A significant improvement (P < 0.001) was seen in the study group in both PCS (from mean ± SD of 37.50 ± 9.58 to 43.7 ± 8.73) and MCS (from 45.87 ± 9.57 to 53.35 ± 7.9.) with minor variations in patients of various departments.
Conclusion: A short-term Yoga therapy program leads to a remarkable improvement in the quality of life of the subjects and can contribute favorably in the management of psychosomatic disorders.

Background: Sexual dysfunction (SD) is not commonly reported by persons with schizophrenia unless an enquiry is made by a doctor or staff during routine clinical visits.
Materials and Methods: A cross-sectional study was carried out to determine reporting of drug-induced sexual side-effects and the attitude of the treating team in clarifying or detecting this issue.
Results: A vast majority of professionals (73.2%) did not enquire about SDs in routine clinical setting and admitted that they lack expertise based on the Attitude Survey Questionnaire. More than one-third of the patients (35.3%) attributed sexual side-effects to medications. Many patients (91.7%) reported good to fair tolerance to sexual side-effects according to the Psychotropic Related Sexual Dysfunction Questionnaire.
Conclusion: The treating team plays a crucial role. Sexual side-effects are often under-reported and need to be addressed by the treating physician.

Background: Psychological factors and psychiatric disorders play a role in a variety of gastrointestinal illnesses, including esophageal diseases.
Aim: The aim of the present study was to evaluate the frequency of gastroesophageal reflux disease symptoms in patients with schizophrenia in Turkey.
PatientsandMethods: Ninety-eight patients with schizophrenia and one hundred control individuals were enrolled in the study, which was undertaken at the Manisa State Hospital for Mental Health and Neurological Disorders and Celal Bayar University Gastroenterology Department. Case and control subjects alike underwent 30-45 min oral interviews conducted by a designated study coordinator (E.K.). The coordinator gathered information about demographic characteristics, social habits, and a large variety of symptoms suggestive of reflux disease or other gastrointestinal conditions.
Results: In terms of reflux symptoms, cough was the only significant association in schizophrenic patients than controls. Heartburn and regurgitation were more frequent in schizophrenic patients who smoked than in controls who were smokers. However, the prevalence of reflux symptoms in cigarette smokers versus nonsmoker patients with schizophrenia was similar.
Heartburn and/or regurgitation occurred more frequently in patients with schizophrenic than controls with alcohol use.
Conclusions: Psychiatric disorders might indirectly affect esophageal physiology through increased consumption of alcohol and nicotine.

Background: Studies conducted in several countries have found an increase in suicide rates in custody than the general population.
Aims: The aim was to assess the trends of suicide in custody and to identify characteristics.
MaterialsandMethods: We examined all available files of the death of people in custody through 2001 to 2010. Information collected included age, sex, type of custody, place of death, presence of any associated disease, history of any psychiatric illness, substance abuse, and cause of death.
Results: A total 173 autopsies was performed out of which 14 cases were of suicide. The mean age was 31.71 years. 71.42% deaths were noted in police lock-ups while 28.57% were recorded in prison. Hanging was the common method of suicide followed by poisoning.
Conclusion: Suicide in custodial setting is preventable problem in India. Preventing suicide in custody needs cooperation and coordination from various agencies.